Twenty-five years' experience with isolated bicuspid aortic valve repair: impact of commissural orientation.

OBJECTIVES: Repair of the bicuspid aortic valve has evolved in the past 25 years. The aim of this study was to review and analyze the long-term durability of isolated BAV repair with particular focus on commissural orientation (CO).

METHODS: All patients who underwent bicuspid aortic valve repair for severe aortic regurgitation between 10/1998 and 12/2022 were included. The study group consists of all patients operated after 2009 ie, since CO modification. The control group includes patients who were operated before 2009. Commissural orientation was classified as symmetric, asymmetric, and very asymmetric.

RESULTS: Overall, 594 adult patients (93% male; mean age 42 years) were included. At 15 years, survival was 94.8% (SD : 2.2); freedom from reoperation was 86.8% (SD : 2.3). Freedom from AI≥II was 70.8% (SD : 4.7) at 15 years. Modification of commissural orientation by sinus plication was performed in 200 (33.7%) instances. Using competing risks analysis, the absence of eH measurement (P = 0.018), very asymmetric CO (P = 0.028), the presence of calcification (P < 0.001), the use of pericardial patch (P < 0.001), the use of subcommissural sutures (P < 0.001), and preoperative endocarditis (P = 0.005) were identified as independent predictors for reoperation. Follow-up was 97% complete (4228 patient-years); mean follow-up was 7 years (SD : 5).

CONCLUSIONS: Isolated bicuspid aortic valve repair leads to good survival and durability in all morphologic types if cusp repair is guided by effective height, suture annuloplasty is performed, and CO is modified using sinus plication in asymmetrical valves. Very asymmetrical valves may should be treated with a lower threshold for replacement.